The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Prescription for ceftriaxone PO every 12 hours.

A 26-year-old client.

Blood pressure is 80/48 mm Hg.

Admitted after a motor vehicle collision.

Answer and Explanation

The Correct Answer is C

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

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Correct Answer is B

Explanation

A. Advise the UAP to hold the thermometer securely in place for a full three minutes is incorrect because tympanic thermometers provide quick readings, typically within a few seconds, and do not require prolonged placement.

B. Use positive reinforcement to affirm that the procedure is being performed correctly is the correct action. For adult clients, the auricle should be pulled up and back to straighten the ear canal for accurate tympanic temperature measurement. Positive reinforcement supports the UAP's learning and confidence.

C. Demonstrate the correct technique for pulling the client's auricle down and back is incorrect for adult clients. Pulling the auricle down and back is appropriate for children under 3 years old, not adults.

D. Remind the UAP to lubricate the thermometer before gently inserting in the ear is not appropriate. Tympanic thermometers do not require lubrication, as they are designed for non-invasive and quick use.

A. Turgor. B. Blood pressure. C. Weight. D. Lung sounds.

Correct Answer is C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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